Background Clinical practice guidelines for mild traumatic brain injury emphasise proactive management of mental health complications. We evaluated the effectiveness of an automated guideline implementation tool for reducing the risk of mental health disorders after mild traumatic brain injury compared with usual care. Methods We conducted a triple-blind (patient, provider, and assessor), cluster-randomised controlled trial. Adults (age 18–69 years) with recent (<72 h) mild traumatic brain injury were recruited from six emergency departments and two urgent care centres in the Greater Vancouver Area, BC, Canada. Enrolled patient participants identified a primary care clinic where they could access follow-up care. There were no additional eligibility criteria for primary care clinics. The clinics were randomised (1:1) to usual care or the intervention (guideline implementation tool) using a concealed permuted block sequence generated by a statistician independent from the study. When a subsequently enrolled patient participant nominated a clinic that already been randomised, that clinic’s allocation was entered manually. Participants were masked to the study hypotheses and the difference between the two interventions. Clinics were masked to the same and not informed that their behaviour was an outcome of interest. Outcome assessors were masked to randomisation allocations. The intervention comprised sending letters to participants and their designated clinics at 2 weeks and 12 weeks post-injury: generic letters about mild traumatic brain injury in the usual care group, and tailored letters with actionable mental health screening test results and recommendations about mental health disorders after mild traumatic brain injury in the intervention group. The main outcome measure was new or worsened mental health disorder (major depressive episode, any anxiety disorder, or post-traumatic stress disorder, excluding disorders deemed to be pre-existing and stable) at 26 weeks, as assessed by the Mini International Neuropsychiatric Interview V.7.0.2. Analyses were performed in all enrolled participants associated with a randomised clinic using generalised estimation equations that accounted for clustering and incorporated inverse probability weights to address potential attrition bias. The trial was registered at ClinicalTrials.gov (NCT04704037) and is completed. Findings Between Feb 1, 2021, and Nov 1, 2022, 4062 patients were approached for potential study inclusion, of whom 537 participants were enrolled from 269 randomised clinics (clusters, which included one to 13 patients [median 1]), with a retention rate of 93%. 136 clinics with 283 patients were assigned to the intervention and 133 clinics with 254 patients were assigned to usual care. All enrolled patients were included in the analysis of the primary outcome. 142 (56%) of 254 participants in the usual care group and 145 (51%) of 283 participants in the intervention group identified as women. 171 (67%) of 254 participants in the usual care group and 176 (62%) of 283 participants in the intervention group were White. The median age was 38·0 years (IQR 29·0–51·0) in the usual care group and 33 years (25·5–49·0) in the intervention group. At a median of 27 weeks (IQR 23–28) post-injury, 77 (30%) of 254 participants in the usual care group and 84 (30%) of 283 in the intervention group developed a new or worsening mental health disorder. The estimated between-group difference in the primary outcome was –1·5% (95% CI –10·3 to 7·3). Three (1%) of the 499 participants who completed the outcome assessment reported being distressed by the study procedures. No other adverse events were reported. Interpretation The guideline implementation tool designed for proactive management of mental health complications after mild traumatic brain injury did not result in clinically meaningful reductions in the risk of mental health disorders at 26 weeks post-injury compared with usual care. A more intensive implementation intervention is likely to be necessary to achieve this outcome. Funding Canadian Institutes for Health Research.

Patients with chest pain and symptoms of acute coronary syndromes account for > 600,000 emergency department (ED) visits annually in Canada. Of these patients, 85% do not have acute coronary syndromes, and most are discharged from the ED after a thorough evaluation. However, a large proportion of these patients are referred for outpatient cardiac testing after ED discharge, even though their short-term risk of major adverse cardiac events (MACE), including death, new myocardial infarction, and need for revascularization, is very small. These referrals contribute to substantial low-value healthcare utilization, and limit access for those patients who are more likely to benefit from objective testing.Existing risk-prediction tools-developed prior to the advent of new high-sensitivity cardiac troponin assays-were derived in nonrepresentative populations, and when applied to ED patients with low cardiac troponin concentrations, systematically overestimate the short-term risk of MACE.This multicentre prospective cohort study will enroll ED patients with chest pain to derive and validate a novel risk prediction tool that distinguishes patients at low risk of MACE who do not require further cardiac testing from those who may benefit from additional cardiac testing. We will enroll 6500 patients in 13 Canadian EDs and prospectively follow them to ascertain a primary outcome of MACE within 30 days after their index ED encounter. The risk-prediction tool developed in this project will guide the safe, efficient, and appropriate referral of ED patients with chest pain. Clinical Trial Registration:NCT06743672.

Artificial intelligence (AI) offers opportunities for managing the complexities of clinical care in the emergency department (ED), and Clinical Decision Support has been identified as a priority application. However, there is a lack of published guidance on how to rigorously develop and evaluate these tools. We sought to answer the question, “What methodological standards should be applied to the development of AI-based Clinical Decision Support tools in the ED?”. We conducted an iterative consensus-establishing activity involving a subcommittee with AI expertise followed by surveys and a live facilitated discussion with participants of the 2024 Canadian Association of Emergency Physicians Research Symposium in Saskatoon. We augmented analysis of participant feedback with large language models. We established 11 recommendations AI-based Clinical Decision Support development including the selection of a relevant problem and team of experts, standards of data quality and quantity, novel AI-specific reporting guidelines, and adherence to principles of ethics and privacy. We removed the recommendation regarding model interpretability from the final list due to a lack of consensus. These 11 recommendations provide guiding principles and methodological standards for emergency medicine researchers to rigorously develop AI-based Clinical Decision Support tools and for clinicians to gain knowledge and trust in using them.

Implication statement Rural and remote physicians face challenges including management of critically ill patients. At eleven British Columbia resident teaching sites, seven of which were rural, we developed interactive video simulation sessions for treating such patients, and these were video-preceptored by a remotely located physician providing real-time debriefing. Family medicine residents found this program acceptable and educational, felt it increased confidence in managing sick patients, and could lead to future rural experiences and retention. Given this program additionally decreases cost and time of simulations due to less travel, we anticipate similar benefits for other Canadian family medicine programs.

Our recent improved understanding of traumatic brain injury (TBI) comes largely from cohort studies of TBI patients with indication for computed tomography (CT). Using CT head as an inclusion criterion may overestimate poor outcomes after TBI with Glasgow Coma Scale (GCS) 13-15. We aimed to compare outcomes after TBI in adults who had a head CT scan (with negative findings) versus those who had no CT when presenting to an emergency department. This was a secondary analysis of a trial that recruited adults with GCS = 13-15 after TBI in Vancouver, Canada. We included 493 participants (18-69 years, 54% female), after removing n = 19 with traumatic abnormalities on CT (intracranial and/or skull fracture). Outcomes were Glasgow Outcome Scale Extended (GOSE), Rivermead Post-Concussion Symptoms Questionnaire (RPQ), Patient Health Questionnaire (PHQ)-9, and generalized anxiety disorder (GAD)-7 at 6 months post-injury. Over half (55%) of participants received a CT. At 6 months, 55% of participants with CT and 49% without CT had functional limitations on GOSE; 32% with CT and 33% without CT reported severe post-concussion symptoms (RPQ ≥16); 26% (with CT) and 28% (without CT) screened positive for depression (PHQ-9 ≥ 10), and 25% (with CT) and 28% (without CT) screened positive for anxiety (GAD-7 ≥ 8). In regression adjusted for personal variables, participants with CT had somewhat higher odds of worse functioning (ordinal GOSE; 1.4, 95% CI 1.0-2.0) but similar odds of severe post-concussion symptoms (1.1, 95% CI: 0.7-1.7), and depression (1.1, 95% CI: 0.7-1.7) and anxiety (1.0, 95% CI: 0.6-1.5) symptoms. Adults with and without head CT have mostly comparable outcomes from TBI with GCS = 13-15. Requiring CT by clinical indication for study entry may not create problematic selection bias for outcome research.

Background: Multiple jurisdictions reported a significant increase in out-of-hospital cardiac arrest (OHCA) incidence over the past decade, however the reasons for this remain unclear. We investigated how drug-associated OHCA (DA-OHCA) contributed to overall OHCA incidence, and whether the likelihood of treatment by emergency medical services (EMS) was associated with DA-OHCA classification. Methods: Using a large provincial cardiac arrest registry, we included consecutive, non-traumatic adult OHCA from 2016-2022. We classified as drug-associated if there were historical accounts of non-prescription drug use within the preceding 24 hours or evidence of paraphernalia at the scene. We examined year-by-year trends in OHCA and DA-OHCA incidence. We also investigated the association between DA-OHCA and odds of EMS treatment using an adjusted logistic regression model. Results: Of 33,365 EMS-assessed cases, 1,985/18,591 (11%) of EMS-treated OHCA and 887/9,200 (9.6%) of EMS-untreated OHCA were DAOHCA. Of EMS-treated DA-OHCA, the median age was 40 years (IQR 31-51), 1,059 (53%) had a known history of non-prescription drug use, and 570 (29%) were public-location. From 2016 to 2022, EMS-treated OHCA incidence increased from 60 to 79 per 100,000 person-years; EMS-treated DA-OHCA incidence increased from 3.7 to 9.1 per 100,000 person-years. The proportion of overall OHCA classified as DA-OHCA increased from 6.1% to 11.5%. DA-OHCA was associated with greater odds of EMS treatment (AOR 1.34; 95%CI 1.13-1.58). Conclusion: Although EMS-treated DA-OHCA incidence increased by nearly three-fold, it comprised a minority of the overall OHCA increase during the study period. DA-OHCA was associated with an increased likelihood of EMS treatment.

A 51-year-old man presented to the emergency department with 8 hours of diffuse abdominal pain. His history was noteworthy for remote prosthetic aortic and tricuspid valve replacements. He had a temperature of 37.2°C (99.0°F), a pulse rate of 120 beats/min, blood pressure of 93/45 mm Hg, and diffuse abdominal tenderness. Initial laboratory test results showed a WBC count of 13,000/mm3 (reference range 4,000 to 10,000/mm3) and a lactate level of 14.8 mmol/L (normal value <1.9 mmol/L). Bedside ultrasonography of the aorta (Figure 1 and Video E1, available online at http://www.annemergmed.com) revealed shadowing superior to the renal arteries. Contrast-enhanced computed tomography (CT) (Figure 2) demonstrated a tricuspid valve in the correct position and an aortic valve located in the aorta superior to the renal arteries.Figure 2Coronal CT with the embolized aortic valve appearing as a reverse B (arrow) immediately superior to the takeoff of the renal arteries. Note the correctly positioned tricuspid valve (arrowhead).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Embolization of prosthetic aortic valve. Valve embolization is rare and typically observed as a complication of transcatheter aortic valve replacement. This generally occurs periprocedurally1Tay E.L. Gurvitch R. Wijeysinghe N. et al.Outcome of patients after transcatheter aortic valve embolization.JACC Cardiovasc Interv. 2011; 4: 228-234Crossref PubMed Scopus (90) Google Scholar and mandates immediate removal of the displaced valve. The patient lost pulses in his lower extremities and was expeditiously taken to the vascular suite for endoscopic valve retrieval but deteriorated and ultimately experienced cardiac arrest. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3MmQzYmI2ZjI0OGM0OWJhZTMwNmFjZmFlOWY1MDBhYyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc5Mzk4NTE5fQ.L-pngnC5zdKLHUX4X05viEJxw38-Om5EKGg22js8KSecnVNk4MiEN8AN1dYMRU6lPZVrmfTbpO5kdXaiIrhG5RcaiuyOpeS7igT7S6iT0NnJPBx3ldIkiVc8aBVoWE_swS9uCOGgP1hmWlJea9wWzWfAu84eGkbost6fOrfWqDdUUHWYrlaMGg19fz-l_-UysAApvvfLa8OIad3KJo23SATW6W5QidRxmv5zKnu4liiq_oJQuxjg78eC2bcGfM8ltQsZLZp4C5Abaqaj3Nr4RL51ch4iWmG8TLj-lBk5jWGw0WJAIjko2UnObDSjVmp4XcvxeMzo68MDGH4KB2PQhQ Download .mp4 (2.88 MB) Help with .mp4 files Video E1Longitudinal abdominal aortic ultrasonography with acoustic shadowing at 00:00 to 00:02 and 00:06 and correctly placed tricuspid valve at 00:04 to 00:05.

Clinical trials and guidelines support the use of very low high-sensitivity cardiac troponin (hs-cTn) results to rule-out a myocardial infarction (MI) ( 1) Jaffe A.S. Body R. Mills N.L. Aakre K.M. Collinson P.O. Saenger A. Hammarsten O. Wereski R. Omland T. Sandoval Y. Ordonez-Llanos J. Apple F.S. IFCC Committee on Cardiac Bio-Markers. Single Troponin Measurement to Rule Out Myocardial Infarction: JACC Review Topic of the Week. J Am Coll Cardiol. 2023 Jul 4; 82: 60-69 Crossref Scopus (7) Google Scholar ). The International Federation of Clinical Chemistry and Laboratory Medicine Committee on Clinical Applications of Cardiac Biomarkers committee, through a modeling approach, suggests assays need to have a lower limit near 3 ng/L and an analytical variation of 10% below 7 ng/L if these low values are to perform consistently in practice ( 2) Aakre K.M. Apple F.S. Mills N.L. Meex S.J.R. Collinson P.O. International Federation of Clinical Chemistry Committee on Clinical Applications of Cardiac Biomarkers (IFCC C-CB)Lower Limits for Reporting High-Sensitivity Cardiac Troponin Assays and Impact of Analytical Performance on Patient Misclassification. Clin Chem. 2023 Dec; 15hvad185 Google Scholar ). Our objectives for the present study were to assess: i) if any type of instrument or individual instrument could achieve a coefficient of variation (CV) of ≤10% at very low hs-cTn cut-offs (i.e., targets) recommended in clinical pathways; ii) the frequency of results at the hs-cTn target, above the target and below the target, with the latter group representing potential misclassification to the low risk group where the target level would in the intermediate risk range.

Background People with opioid use disorder (OUD) are high-risk for short-term mortality and morbidity. Emergency department (ED) interventions can reduce those risks, but benefits wane without ongoing community follow-up. Objective To evaluate an ED-based intensive community outreach program. Methods At two urban EDs between October 2019 and March 2020, we enrolled patients with OUD not currently on opioid agonist therapy (OAT) in a prospective cohort study evaluating a one-year intensive community outreach program, which provided ongoing addictions care, housing resources, and community support. We surveyed patients at intake and at scheduled outreach encounters at one, two, six, and twelve months. Follow-up surveys assessed OAT uptake, addictions care engagement, housing status, quality of life scores, illicit opioid use, and outreach helpfulness. We used descriptive statistics for each period and conducted sensitivity and subgroup analyses to account for missing data. Results Of 84 baseline participants, 29% were female and 32% were housed, with a median age of 33. Sixty participants (71%) completed at least one follow-up survey. Survey completion rates were 37%, 38%, 39%, and 40% respectively at one, two, six, and twelve months. Participants had a median of three outreach encounters. Among respondents, OAT was 0% at enrolment and ranged from 38% to 56% at follow-up; addictions care engagement was 22% at enrolment and ranged from 65% to 81% during follow-up; and housing was 40% at enrolment and ranged from 48% to 59% during follow-up. Improvements from baseline to follow-up occurred for all time periods. OAT and engagement in care benefits were maintained in sensitivity and subgroup analyses. Respondents rated the outreach program as helpful at all time periods, Conclusion An ED-initiated intensive outreach program for patients with OUD not yet on OAT was associated with a persistent increase in OAT use and engagement in care, as well as housing.

For emergency department (ED) patients with cardiac chest pain, introduction of high-sensitivity troponin (hsTnT) pathways has been associated with reductions in length of stay of less than 1 h. At two urban Canadian sites, we introduced hsTnT on January 26, 2016. While the prior diagnostic algorithm required troponin testing at 0 and 6 h, serial hsTnT serial testing was conducted at 0 and 3 h. We identified consecutive patients who presented with cardiac chest pain from January 1, 2015, to March 31, 2017, along with 30-day outcomes. The primary outcome was a missed 30-day major adverse cardiac event, (MACE) defined as death, revascularization, or readmission for myocardial infarction occurring in a patient-discharged home with a minimizing diagnosis and without cardiac-specific follow-up. Secondary outcomes included admission rate, ED length of stay, and MACE. We compared pre- and post- implementation periods using descriptive methods and repeated this analysis in patients with noncardiac chest pain. We collected 5585 patients with cardiac chest pain, (2678 pre- and 2907 post-introduction) and 434 had (7.8

BACKGROUND:Clinicians may make prognostication decisions for out-of-hospital cardiac arrest (OHCA) using historical details pertaining to non-prescription drug use. However, differences in outcomes between OHCAs with evidence of non-prescription drug use, compared to other OHCAs, have not been well described. METHODS:We included emergency medical service-treated OHCA in the British Columbia Cardiac Arrest Registry (January/2019-June/2023). We classified cases as "non-prescription drug-associated cardiac arrests" (DA-OHCA) if there was evidence of non-prescription drug use preceding the OHCA, including witness accounts of use within 24 h or paraphernalia at the scene. We fit logistic regression models to investigate the association between DA-OHCA (vs. other cases) and favourable neurological outcome (Cerebral Performance Category [CPC] 1-2) and survival at hospital discharge, and return of spontaneous circulation (ROSC). RESULTS:Of 18,426 OHCA, 2,171 (12%) were classified as DA-OHCA. DA-OHCA tended to be younger, unwitnessed, occur during the evening or night, and present with a non-shockable rhythm, compared to other OHCA. DA-OHCA (221 [10%]) had a greater proportion (difference 1.8%; 95% CI 0.49-3.2) with favourable neurological outcomes compared to other OHCA (1,365 [8.4%]). Adjusted models did not identify an association of DA-OHCA with favourable neurological outcome (OR 1.08, 95% CI 0.87-1.33) or survival to hospital discharge (OR 1.13, 95% CI 0.93-1.38), but did demonstrate an association with ROSC (OR 1.13, 95% CI 1.004-1.27). CONCLUSION:In unadjusted models, DA-OHCA was associated with an improved odds of survival and favourable neurological outcomes at hospital discharge, compared to other OHCA. However, we did not detect an association in adjusted analyses.

Background: The Vancouver Chest Pain Rule is designed to safely reduce hospital admissions of emergency department patients with chest pain. We describe the impact of provincial implementation of the Vancouver Chest Pain Rule on hospital admissions. Methods: From 2017 to 2018, in 29 British Columbia emergency departments that had a wide range of patients and resources, we encouraged the use of the Vancouver Chest Pain Rule via a coordinated campaign that included in -person meetings, webinars, and online messaging. In a retrospective cohort, we collected all chest pain patients from 2016 to 2017 (before) and 2018 to 2019 (after) for the primary outcome of 30 -day hospital admission. Results: We collected 94 058 (before) and 90 170 (after) visits. Median ages (56), gender (female: 50%), and comorbidities were similar. The admission rate decreased from 23.7% to 22.5% (relative decrease 5.3%; absolute decrease 1.3%). Conclusions: An organized implementation of the Vancouver Chest Pain Rule was associated with a 5.3% relative reduction in hospitalizations, which translates to 1300 fewer hospitalizations annually.

Persistent symptoms are common after a mild traumatic brain injury (mTBI). The Post-Concussion Symptoms (PoCS) Rule is a newly developed clinical decision rule for the prediction of persistent post-concussion symptoms (PPCS) 3 months after an mTBI. The PoCS Rule includes assessment of demographic and clinical characteristics and headache presence in the emergency department (ED), and follow-up assessment of symptoms at 7 days post-injury using two thresholds (lower/higher) for symptom scoring. We examined the PoCS Rule in an independent sample. We analyzed a clinical trial that recruited participants with mTBI from EDs in Greater Vancouver, Canada. The primary analysis used data from 236 participants, who were randomized to a usual care control group, and completed the Rivermead Postconcussion Symptoms Questionnaire at 3 months. The primary outcome was PPCS, as defined by the PoCS authors. We assessed the overall performance of the PoCS rule (area under the receiver operating characteristic curve [AUC]), sensitivity, and specificity. More than 40% of participants (median age 38 years, 59% female) reported PPCS at 3 months. Most participants (88%) were categorized as being at medium risk based on the ED assessment, and a majority were considered as being at high risk according to the final PoCS Rule (81% using a lower threshold and 72% using a higher threshold). The PoCS Rule showed a sensitivity of 93% (95% confidence interval [CI], 88-98; lower threshold) and 85% (95% CI, 78-92; higher threshold), and a specificity of 28% (95% CI, 21-36) and 37% (95% CI, 29-46), respectively. The overall performance was modest (AUC 0.61, 95% CI 0.59, 0.65). In conclusion, the PoCS Rule was sensitive for PPCS, but had a low specificity in our sample. Follow-up assessment of symptoms can improve risk stratification after mTBI.

Background: Previous studies have reported race-based health disparities in North America. It is unknown if emergency medical service (EMS) treatment of out-of- hospital cardiac arrest (OHCA) varies based on race. We sought to compare markers of resuscitation intensity among different racial groups. Methods: Using data of adult EMS-treated OHCAs from the Trial of Continuous or Interrupted Chest Compressions During CPR, we analyzed data from participants for whom on-scene return of spontaneous circulation (ROSC) was not achieved. We fit multivariate regression models using a generalized estimating equation, to estimate the association between patient race (White vs. Black vs. "Other") and the following markers for resuscitation intensity: (1) resuscitation attempt duration; (2) intra-arrest transport; (3) number of epinephrine doses; (4) EMS arrival-to-CPR interval, and (5) 9-1-1 to first shock. Results: From our study cohort of 5370 cases, the median age was 65 years old (IQR: 53-78), 2077 (39 %) were women, 2121 (39 %) were Black, 596 (11 %) were "Other race", 2653 (49 %) were White, and 4715 (88 %) occurred in a private location. With reference to White race, Black race was associated with a longer resuscitation attempt duration and a lower number of epinephrine doses; Black and "Other" race were both associated with a lower odds of intra-arrest transport. Conclusion: We identified race-based differences in EMS resuscitation intensity for OHCA within a North American cohort, although 40% of race data was missing from this dataset. Future research investigating race-based differences in OHCA management may be warranted.

Background: The impact of extreme heat on out-of-hospital cardiac arrest (OHCA) incidence and outcomes is under-studied. We investigated OHCA incidence and outcomes over increasing temperatures. Methods: We included non-traumatic EMS (Emergency Medical Services)-assessed OHCAs in British Columbia during the warm seasons of 2020-2021. We fit a time-series quasi-Poisson generalized linear model to estimate the association between temperature and incidence of both EMS-assessed, EMS-treated, and EMS-untreated OHCAs. Second, we employed a logistic regression model to estimate the association between "heatwave" periods (defined as a daily mean temperature > 99th percentile for >= 2 consecutive days, plus 3 lag days) with survival and favourable neurological outcomes (cerebral performance category <= 2) at hospital discharge. Results: Of 5478 EMS-assessed OHCAs, 2833 were EMS-treated. OHCA incidence increased with increasing temperatures, especially exceeding a daily mean temperature of 25 degrees C Compared to the median daily mean temperature (16.9 degrees C), the risk of EMS-assessed (relative risk [RR] 3.7; 95%CI 3.0-4.6), EMS-treated (RR 2.9; 95%CI 2.2-3.9), and EMS-untreated (RR 4.3; 95%CI 3.2-5.7) OHCA incidence were higher during days with a temperature over the 99th percentile. Of EMS-treated OHCAs, during the heatwave (n = 179) and non-heatwave (n = 2654) periods, 4 (2.2%) and 270 (10%) survived and 4 (2.2%) and 241 (9.2%) had favourable neurological outcomes, respectively. Heatwave period OHCAs had decreased odds of survival (adjusted OR 0.28; 95%CI 0.10-0.79) and favourable neurological outcome (adjusted OR 0.31; 95%CI 0.11-0.89) at hospital discharge, compared to other periods. Conclusion: Extreme heat was associated with a higher incidence of OHCA, and lower odds of survival and favourable neurological status at hospital discharge.

Abstract Background Illicit drug toxicity (i.e., overdose) is the leading cause of death in British Columbia (BC) for people aged 10–59. Stimulants are increasingly detected among drug toxicity deaths. As stimulant use and detection in deaths rises, it is important to understand how people who die of stimulant toxicity differ from people who die of opioid toxicity. Methods BC Coroners Service records were retrieved for all people who died of unintentional illicit drug toxicity (accidental or undetermined) between January 1, 2015, and December 31, 2019, whose coroner investigation had concluded and who had an opioid and/or stimulant detected in post-mortem toxicology and identified by the coroner as relevant to the death (N = 3788). BC Chronic Disease Registry definitions were used to identify people with chronic disease. Multinomial regression models were used to examine the relationship between chronic disease diagnoses and drug toxicity death type. Results Of the 3788 deaths, 11.1% (N = 422) had stimulants but not opioids deemed relevant to the cause of death (stimulant group), 26.8% (N = 1014) had opioids but not stimulants deemed relevant (opioid group), and 62.1% (N = 2352) had both opioids and stimulants deemed relevant (opioid/stimulant group). People with ischemic heart disease (1.80 (1.14–2.85)) and people with heart failure (2.29 (1.25–4.20)) had approximately twice the odds of being in the stimulant group as compared to the opioid group. Conclusions Findings suggest that people with heart disease who use illicit stimulants face an elevated risk of drug toxicity death. Future research should explore this association and should identify opportunities for targeted interventions to reduce drug toxicity deaths among people with medical comorbidities.

BACKGROUND:An analytical benchmark for high-sensitivity cardiac troponin (hs-cTn) assays is to achieve a coefficient of variation (CV) of ≤ 10.0 % at the 99th percentile upper reference limit (URL) used for the diagnosis of myocardial infarction. Few prospective multicenter studies have evaluated assay imprecision and none have determined precision at the female URL which is lower than the male URL for all cardiac troponin assays.METHODS:Human serum and plasma matrix samples were constructed to yield hs-cTn concentrations near the female URLs for the Abbott, Beckman, Roche, and Siemens hs-cTn assays. These materials were sent (on dry ice) to 35 Canadian hospital laboratories (n = 64 instruments evaluated) participating in a larger clinical trial, with instructions for storage, handling, and monthly testing over one year. The mean concentration, standard deviation, and CV for each instrument type and an overall pooled CV for each manufacturer were calculated.RESULTS:The CVs for all individual instruments and overall were ≤ 10.0 % for two manufacturers (Abbott CVpooled = 6.3 % and Beckman CVpooled = 7.0 %). One of four Siemens Atellica instruments yielded a CV > 10.0 % (CVpooled = 7.7 %), whereas 15 of 41 Roche instruments yielded CVs > 10.0 % at the female URL of 9 ng/L used worldwide (6 cobas e411, 1 cobas e601, 4 cobas e602, and 4 cobas e801) (CVpooled = 11.7 %). Four Roche instruments also yielded CVs > 10.0 % near the female URL of 14 ng/L used in the United States (CVpooled = 8.5 %).CONCLUSIONS:The number of instruments achieving a CV ≤ 10.0 % at the female 99th-percentile URL varies by manufacturer and by instrument. Monitoring assay precision at the female URL is necessary for some assays to ensure optimal use of this threshold in clinical practice.

ObjectiveTo identify individual and site-related factors associated with frequent emergency department (ED) buprenorphine/naloxone (BUP) initiation. BUP initiation, an effective opioid use disorder (OUD) intervention, varies widely across Canadian EDs.MethodsWe surveyed emergency physicians in 6 Canadian provinces from 2018 to 2019 using bilingual paper and web-based questionnaires. Survey domains included BUP-related practice, demographics, attitudes toward BUP, and site characteristics. We defined frequent BUP initiation (the primary outcome) as at least once per month, high OUD prevalence as at least one OUD patient per shift, and high OUD resources as at least 3 out of the following 5 resources: BUP initiation pathways, BUP in ED, peer navigators, accessible addiction specialists, and accessible follow-up clinics. We excluded responses from sites with <50% participation (to minimize non-responder bias) and those missing the primary outcome. We used univariate analysis to identify associations between frequent BUP initiation and factors of interest, stratifying by OUD prevalence.ResultsWe excluded 3 responses for missing BUP initiation frequency and 9 for low response rate at one ED. Of the remaining 649 respondents from 34 EDs, 374 (58%) practiced in metropolitan areas, 384 (59%) reported high OUD prevalence, 312 (48%) had high OUD resources, and 161 (25%) initiated BUP frequently. Age, gender, board certification and years in practice were not associated with frequent BUP initiation. Site-specific factors were associated with frequent BUP initiation (high OUD resources [OR 6.91], high OUD prevalence [OR 4.45], and metropolitan location [OR 2.39],) as were individual attitudinal factors (willingness, confidence, and responsibility to initiate BUP.) Similar associations persisted in the high OUD prevalence subgroup.ConclusionsIndividual attitudinal and site-specific factors were associated with frequent BUP initiation. Training to increase physician confidence and increasing OUD resources could increase BUP initiation and benefit ED patients with OUD.